psychology-hope and research

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tirsdag 21. oktober 2014

Our
powerful mind and hope.

One
of the main arguments for continuing drug treatment for depression, psychosis
and bipolar disorder is that you will get worse from stopping the drugs, especially
if they are stopped abruptly. These are findings from mainstream psychiatry.

However,
if we combine this information with the methodology of the randomized
controlled trial, we may see that these drug trials do not show efficacy of
drugs, and may not be usable to show safety. The positive side to this is that
the trials may actually demonstrate the healing power of our own minds.

When drugs
are tested, patients are given a placebo for 4 to 14 days in order to wash out
the drug that they have been taking before the trial. Patients do not know that
they are getting a placebo, and many of them may think that they are lucky and
have been given the new wonder drug.

During this
washout period, many individuals react very well, so well that they do not have
enough psychological problems to enter the real drug trial. These are so-called
placebo responders. They are removed from the trial, since they are not
depressed or psychotic enough to take part in the research project.

This seems
like it is going to give the drug and unfair advantage. However, if the drug
group and the placebo group are of the same size, this does not actually
provide an advantage for the drug. But something much more significant is
happening.

The placebo
washout period is used to ensure that all participants have brains free from
the previous drug they were taking before they start treatment with the new drug.

That means
that at the end of the placebo washout period, all the patients are in acute
withdrawal. One would reasonably expect these patients to do quite poorly, to
be quite disturbed. Some of them are , but many who had a problem when they
were on the drug, actually get well from stopping the drug cold turkey.

However,
those who react badly to the cold turkey withdrawal get to continue. Half of
them then get a drug very similar to the one they had abruptly stopped, and the
rest, the placebo group, get to continue on cold turkey withdrawal.

So this is
what we are testing: Difference between continuing cold turkey withdrawal and
getting back a drug very similar to the one you were dependent on.

So the
classic RCT is not at all testing the difference between drug and no-drug

This may
actually explain some strange effects seen in drug trials:

-The
positive effects of the SSRIs start immediately, even if doctors tell their
patients that the drugs have to be taken from 4 to 8 weeks to feel better

-Patients in
the placebo group get a lot of negative effects such as sleeplessness, and
inner turmoil (akathisia). One would not expect such negative placebo effects (nocebo)
from a pill that patients think will actually relieve their problems.

-Effect only
in the severely depressed. Many doctors seem to accept that SSRIs don’t have an
impressive effect on the moderately depressed, but justify their use on the
severely depressed because of a larger difference between placebo and drug for
this group. We know that patients in this severely depressed group must have
taken larger doses of their previous drug for longer times. It is then quite obvious there will be more severe withdrawal reactions in the placebo
group. The group getting back a similar drug will be even more relieved, since
they were very addicted to the previous drug.

-Drugs not
working in children and adolescents. This may be the only case where
participants have not been on a similar drug before they start the trial, and
here we don’t see a difference between drug and placebo.

So what is
being tested in RCT is not at all the difference between a drug and an inactive
pill, we are testing how good it feels to get back something very similar to
the drug you were dependent on, compared to going cold turkey! Anybody who has
had a serious hangover and then “repaired” by taking a few drinks knows this
difference. The relieving drug doesn’t have to be the same: Acute alcohol
delirium can be cured with benzodiazepines since they are similar to alcohol in
effect on the nervous system.

So the first
conclusion may then be that none of these RCTs prove that the drugs work.

The second
conclusion may even be more startling: We cannot say anything about the safety
when we compare a drug to abrupt withdrawal.

One of the
reasons drug companies give for not leaving depression untreated, is the the untreated
patient may die from suicide. One could then think that taking the drug away
from a patient would increase the risk for suicide. So according to drug
company logic, a patient who has abruptly stopped the life-saving drug, would
have a higher risk for suicide than the medicated patient.

This is
confirmed in a veryh large study reported in Journal of Clinical Psychiatry in
2009. The abstract states: “Antidepressant discontinuation showed a significant
risk for suicide attempt as did the period of an abbreviated trial, that is,
stopping before a therapeutic regimen of 56 days had been reached. The highest
risk was associated with initiation, a finding consistent with other studies,
closely followed by periods of dosing changes and discontinuation”. Slowly increasing dose (titration up)
increased the risk to 262% of normal risk. Decreasing dose gradually lead to a
219% increased risk according to the article.1

This means that
patients on placebo have at least doubled suicide risk after 2 weeks in
withdrawal. The 219% risk was on gradual withdrawal, not abrupt, which would
possibly be much worse.

RCTs compare
suicidal ideation on the drug to placebo. Many studies find a doubled risk. One
study found a 6 fold risk for Paxil2. Since the risk in the placebo
group is already doubled, the increased risk from the drug may be 4 to 12 times
the risk of unmedicated depression. The conclusion is difficult to avoid: antidepressants
are extremely hazardous to our health.

However, the
flipside of this problem is quite positive: avoiding medication for depression
is associated with much less suicide!

And now we
come to the truly amazing power of hope in the form of a placebo. Let us take a
typical antidepressant trial with some simple numbers: 100 participants in the
placebo group and 100 in the drug group. Let us be optimistic for the drug and
assume that 60% get well. 50% typically get well on the placebo. This means that
100 out of 200 patients actually would get
well from the placebo, since 50 patients in the drug group also are expected to
get well from just popping a pill whether it is sugar or drug. This means that
only 10% got anything out of the drug. The rest get well on a placebo. The
results are thus that placebo is 5 times more effective than the drug.

If we
combine this with our first observation that placebo treatment is actually
abrupt withdrawal, it becomes really amazing. Going cold turkey off the
previous medication makes 50% of patients well, often instantly in the case of
those who respond in the washout phase. This is very bad advertising for the
makers of the previous drugs. And the new drug is only one fifth as effective
as cold turkey.

There are so
many other things wrong with RCT’s, such as publishing only the positive
trials, that we cannot even be sure of this 10% drug effect.

In addition
to this, even the very pro-drug Dr. Gibbon’s meta-analysis of industry
sponsored trials showed that the placebo reached the exact same level as the
drug just four days later. All this
shows that we can trust our own minds to heal themselves as long as we don’t
add chemicals.

To conclude:
From this analysis it becomes clear that we don’t have ANY research showing the
effects or safety of SSRIs since we are testing cold turkey withdrawal against
getting back a me-too drug. The research shows the opposite of what the drug
makers hoped to find: placebo is extremely effective and has no side effects.
Hope is curing us.

mandag 1. september 2014

Hope for
people with so-called mental illness?

There is a pressing need for
treatment of so-called mental illness in the world. Parents are telling horror
stories of how their children become violent, often with very strong psychotic
symptoms, voices telling them to kill others or themselves etc. These parents
are naturally extremely stressed when the mental health system does not have
anything to offer.

Are these children biologically
ill? The reason for the problem may actually be found somewhere else. What if
it is the treatment that makes these people so violent and crazy at the same
time?

A typical, much too typical
scenario is the following. A boy, let’s
call him John, is too active and has problems concentrating in class. The
parents are concerned that he will not have all the possibilities open for the
future if he continues in school with his concentration problems. They take him
to a doctor who refers to a psychiatrist, and the psychiatrist, using the
diagnostic manual correctly, puts up a diagnosis of ADHD. He tells the parents
that the ADHD explains why John has trouble in school.

This is actually circular reasoning
since the items used to diagnose ADHD describe
school problems. So what the psychiatrist is actually saying is that the reason
John has school problems is that he has problems in school. There are no
biological tests for ADHD, and the symptoms were voted into the diagnostic
manual DSM III , IV and 5.

The doctor says that john should
try out a stimulant medication, such as Ritalin or Adderal for his ADHD. This seems to work fine. John
becomes quiet and almost obsessive about his schoolwork. He gets problem
sleeping and seems bit depressed though.

The doctor gives a “mild sedative”
(benzo) for him to sleep more easily every night.

After some months the depression gets worse
and he starts talking about hearing voices, and says he has thought about
killing himself. Stimulants may cause
mania or psychosis, and may lead to suicide. John’s parents get very worried
and take him to the psychiatrist again. Since the psychiatrist is the one who
has prescribed the stimulant, he naturally thinks that John has got other
problems now and prescribes an antidepressant for the depression and an
antipsychotic for the voices. The parents are worried, but thankful that they
have got treatment for their son.

The antidepressant is stimulating
just like the stimulant, and the resulting symptoms are more thoughts of
wanting to die, more voices, but the antipsychotics seem to make all these
things unimportant. Everything starts to seem unimportant to John, especially
his hygiene, and this creates problems with bullying in school. John does not
like the effect of the antipsychotic. It makes him restless and tired at the
same time, so after a while he refuses to take it, claiming he is not crazy.

A few days after he has stopped
taking the antipsychotics, the voices become really strong and they are talking
about suicide and death all the time. John’s parents are now desperate and they
get him admitted to psychiatric ER against his will. Here he gets more drugs
and is out after 3 days, quite sedated.
However, after some days he does not want to take the new medications either,
since they have much of the same side effects as the old ones. Two days go by, and the same delirious crazy
behavior takes over again.

Is John mentally ill or is he the
victim of a medical culture which is much too quick to medicate, and not
willing to see that these medications have side effects that look like other
mental disorders.

It would not be surprising if most
of the violently crazy youth are that way due to side effects of drug cocktails. There
is no research on most of the combinations in the cocktails, so one cannot say
that they represent evidence based practice.

Imagine if the name of the
medications were alcohol and cocaine. Alcohol is very similar to the benzos and
cocaine is so similar to Ritalin that cocaine addicts cannot feel the
difference if the snort Ritalin. So your child has been made addicted to
cocaine for his concentration problems and then addicted to alcohol at night to
sleep since he gets sleepless from the cocaine use. Would we then maybe think
that we are doing something wrong with this child and not be so surprised that
he can become a danger to self or others ? Would we then think of removing the
cocaine and alcohol to see if things calmed down?

The biggest problem may be giving
antipsychotics to young people who are unstable and rebellious and who want to
live life, have a sex life, not feel drugged in to a stupor and not get fat. It
is very much to be expected that a young person will want to stop the
medication after a while, quickly, and this is almost a guarantee for a
psychotic reaction since the brain has compensated for the drugging by becoming
hypersensitive.

Two very big research projects by
the World Health Organization has shown that when less medication is given in
developing countries, more people get completely well from schizophrenia. Maybe
we can learn something from these countries? Less use of drugs may be just a
part of it. Closer family ties are probably very important. Young people with
psychotic problems are expected to “get over it”, and they are kept in the
family as long as it takes. Even the belief that they have been hexed by
somebody is better than the western belief that we are dealing with permanent
biological disorders that will just destroy the brain more and more. A view
that sees even psychotic symptoms as something we all may experience,
normalizing , may be very liberating. Seeing ADHD symptoms as high energy and
creativity levels are also very comforting. Since no biological markers have
been found for these disorders, with so much money being used and so much
prestige at stake, we may be fairly certain that they don’t exist. Thus taking
the view that the brains of so-called disturbed people are normal, is very
scientifically correct. This should be the so-called null hypothesis, and
anyone claiming otherwise would have to prove the abnormality beyond doubt to
be taken seriously. A completely normal computer may function poorly if there
is a programming error, or some settings are wrong. In the same way, a brain
can function poorly if some of the “settings” are wrong. Schizophrenia may be
conceptualized as a problem of audio settings in the brain. Thoughts become
audible, but are not really more crazy than our normal thoughts. All people may
have severely critical thoughts such as “you are a jerk for doing that”. Put a sound on that thought, and we call it
schizophrenia. Most people can have two voices in the form of thoughts in the
form of a running commentary of action. Imagine a shy boy wanting to ask a girl
for a dance. The thoughts may go like this: Ask, her, this is your chance! No,
I can’t do that, my voice will shake! You can do it. Youhave talked to her many
times before. Yes, but that was before I fell in love with her.

If the person really hears this
dialog in his head, it is considered ad a really bad sign of schizophrenia.

However, thought voices are so
close to being heard that we can easily describe the tone of voice and often
whose voice we are using in our thoughts.

A person with very serious contamination/handwashing OCD can be totally
disabled by it. However, this is also a setting. We all feel the need to wash
our hands before we eat, and surgeons should was their hand like an OCD
patient. So we have different settings at different times.

We can modify these settings
through talk therapy (programming) practical experience (exposure) and
psychological practice. As a psychologist, I see this every day. It is exciting
to see patients again after one or two weeks, to see if they have been able to
reprogram themselves between sessions.

torsdag 28. august 2014

What gives more hope, biology change or psychological retraining?

There is a pressing need for
treatment of so-called mental illness in the world. Parents are telling horror
stories of how their children become violent, often with very strong psychotic
symptoms, voices telling them to kill others or themselves etc. These parents
are naturally extremely stressed when the mental health system does not have
anything to offer.

Are these children biologically
ill? The reason for the problem may actually be found somewhere else. What if
it is the treatment that makes these people so violent and crazy at the same
time?

A typical, much too typical
scenario is the following.A boy, let’s
call him John, is too active and has problems concentrating in class. The
parents are concerned that he will not have all the possibilities open for the
future if he continues in school with his concentration problems. They take him
to a doctor who refers to a psychiatrist, and the psychiatrist, using the diagnostic
manual correctly, puts up a diagnosis of ADHD. He tells the parents that the
ADHD explains why John has trouble in school.

This is actually circular reasoning
since the items used to diagnose ADHD describe
school problems. So what the psychiatrist is actually saying is that the reason
John has school problems is that he has problems in school. There are no
biological tests for ADHD, and the symptoms were voted into the diagnostic
manual DSM III , IV and 5.

The doctor says that john should
try out a stimulant medication, such as Ritalin for his ADHD. This seems to work fine. John
becomes quiet and almost obsessive about his schoolwork. He gets problem
sleeping and seems bit depressed though.

The doctor gives a “mild sedative”
(benzo) for him to sleep more easily every night.

After some months the depression gets worse
and he starts talking about hearing voices, and says he has thought about
killing himself.Stimulants may cause
mania or psychosis, and may lead to suicide. John’s parents get very worried
and take him to the psychiatrist again. Since the psychiatrist is the one who
has prescribed the stimulant, he naturally thinks that John has got other
problems now and prescribes an antidepressant for the depression and an
antipsychotic for the voices. The parents are worried, but thankful that they
have got treatment for their son.

The antidepressant is stimulating
just like the stimulant, and the resulting symptoms are more thoughts of
wanting to die, more voices, but the antipsychotics seem to make all these
things unimportant. Everything starts to seem unimportant to John, especially
his hygiene, and this creates problems with bullying in school. John does not
like the effect of the antipsychotic. It makes him restless and tired at the
same time, so after a while he refuses to take it, claiming he is not crazy. A
few days after he has stopped taking the antipsychotics, the voices become
really strong and they are talking about suicide and death all the time. John’s
parents are now desperate and they get him admitted to psychiatric ER against
his will. Here he gets more drugs and is out after 3 days,quite sedated. However, after some days he
does not want to take the new medications either, since they have much of the
same side effects as the old ones.Two
days go by, and the same delirious crazy behavior takes over again.

Is John mentally ill or is he the
victim of a medical culture which is much too quick to medicate, and not
willing to see that these medications have side effects that look like other
mental disorders.

It would not be surprising if most
of the violently crazy youth are that way due to side effects of drug cocktails. There
is no research on most of the combinations in the cocktails, so one cannot say
that they represent evidence based practice.

Imagine if the name of the
medications were alcohol and cocaine. Alcohol is very similar to the benzos and
cocaine is so similar to Ritalin that cocaine addicts cannot feel the
difference if the snort Ritalin. So your child has been made addicted to
cocaine for his concentration problems and then addicted to alcohol at night to
sleep since he gets sleepless from the cocaine use. Would we then maybe think
that we are doing something wrong with this child and not be so surprised that
he can become a danger to self or others ? Would we then think of removing the
cocaine and alcohol to see if things calmed down?

The biggest problem may be giving
antipsychotics to young people who are unstable and rebellious and who want to
live life, have a sex life, not feel drugged in to a stupor and not get fat. It
is very much to be expected that a young person will want to stop the
medication after a while, quickly, and this is almost a guarantee for a
psychotic reaction since the brain has compensated for the drugging by becoming
hypersensitive.

Two very big research projects by
the World Health Organization has shown that when less medication is given in
developing countries, more people get completely well from schizophrenia. Maybe
we can learn something from these countries? Less use of drugs may be just a
part of it. Closer family ties are probably very important. Young people with
psychotic problems are expected to “get over it”, and they are kept in the
family as long as it takes. Even the belief that they have been hexed by
somebody is better than the western belief that we are dealing with permanent biological
disorders that will just destroy the brain more and more. A view that sees even
psychotic symptoms as something we all may experience, normalizing , may be
very liberating.

Seeing ADHD symptoms as high energy and creativity levels are
also very comforting. Since no biological markers have been found for these
disorders, with so much money being used and so much prestige at stake, we may
be fairly certain that they don’t exist. Thus taking the view that the brains
of so-called disturbed people are normal, is very scientifically correct. This
should be the so-called null hypothesis, and anyone claiming otherwise would
have to prove the abnormality beyond doubt to be taken seriously.

A completely
normal computer may function poorly if there is a programming error, or some
settings are wrong. In the same way, a brain can function poorly if some of the
“settings” are wrong. Schizophrenia may be conceptualized as a problem of audio
settings in the brain. Thoughts become audible, but are not really more crazy than
our normal thoughts. All people may have severely critical thoughts such as “you
are a jerk for doing that”. Put a sound
on that thought, and we call it schizophrenia. Most people can have two voices in
the form of thoughts in the form of a running commentary of action. Imagine a
shy boy wanting to ask a girl for a dance. The thoughts may go like this: Ask,
her, this is your chance! No, I can’t do that, my voice will shake! You can do
it. You have talked to her many times before. Yes, but that was before I fell in
love with her.

If the person really hears this
dialog in his head, it is considered ad a really bad sign of schizophrenia.

However, thought voices are so
close to being heard that we can easily describe the tone of voice and often
whose voice we are using in our thoughts.

A person with very serious contamination/handwashing OCD can be totally
disabled by it. However, this is also a setting. We all feel the need to was
our hands before we eat, and surgeons should was their hand like an OCD
patient. So we have different settings at different times.

We can modify these settings
through talk therapy (programming) practical experience (exposure) and psychological
practice. As a psychologist, I see this every day. It is exciting to see
patients again after one or two weeks, to see if they have been able to
reprogram themselves between sessions.

Excerpt from my book " Hope in psychology", soon to be published on Amazon Kindle.

mandag 25. august 2014

I am a clinical psychologist working in an anxiety and
OCD Clinic at the University of Oslo, Norway. In this clinic we do almost all
the treatment without starting drugs, and for many patients we help them taper
the drugs. One of the reasons for this is that taking drugs for psychological
problems often may be seen as avoidance behavior, and this is exactly what
maintains the anxiety or in many cases makes it worse.

If a person starts
taking a benzodiazepine every time he feels anxious, he will never discover
that it passes by itself and is not dangerous. When doctors give strong drugs
to “combat” anxiety symptoms, they may actually be signaling to patients that
anxiety is dangerous.

The most effective treatment for anxiety disorders of all
kinds, is exposure, and that is exactly the opposite of running away through
drugs. Actually stepping down on drugs very slowly (less than 1% per day) may
be very good exposure training.

I often tell my patients: it is great if the stepping
down gives you a bit more symptoms. Then you get the possibility to learn that
anxiety is not dangerous and that it is by going into it, instead of avoiding, that you get better.

Many people who have anxiety actually think the worst part
of anxiety is the self loathing. They hate themselves for being so weak, not
daring enough, always worried etc.

The opposite should be the case. The ability to be afraid
has enabled humans to survive. Those who were of the worrying kind were the
best survivors in hard stone age times. They would worry about food supplies
for the winter, living conditions, cleanliness, safety for themselves and their
offspring.

Many of the best survivors of hard times could be
diagnosed with generalized anxiety disorder, phobias, OCD and even social
anxiety. In stone age tribes it could be very dangerous to talk to strangers.
People with very low social anxiety could be a risk for themselves and their
tribe.

Fear of heights, snakes, spiders, open spaces etc. have a
distinct survival advantage for humans. It is just in the last centuries that
conditions have changed so that some of these fears are problematic.

Even psychotic symptoms may have given a survival
advantage in earlier times. We all have several thousand verbal thoughts every
day, and often we don’t really pay attention to them. The internal dialog just
keeps on chattering.

How can the brain
signal to us that a thought is more important than others, e.g. “you are in
danger, run to the cave”? The logical thing would be to give more sound to it
than normal thoughts, in other words a thought that sounds like it is spoken by
somebody. This would today be called an auditive hallucination. We often see
that hallucinations come in response to extremely stressful situations.

Trauma victims may develop internal audible voices in
order to make sure the internal dialogue around possibly dangerous situations
is very clear.

Depression may be a very useful reaction to overwork, in
order to slow the person down and avoid exhaustion. It may also function to
slow people down so that they have time to think about things they may have
done wrongly, so that they will be able to change their ways.

Bipolar behavior and ADHD may have its function in
getting projects started, and bringing up many new ideas, even if most of them
have no merit. The energy that is pathologized by these two diagnoses is
probably the reason why we are not still in the stone age and why we have works
of art. Inventors, artists and entrepreneurs are often seen by others as overly
energetic and unrealistic. But they are needed in order to get development.

So what is characteristic with people who get
psychological problems and what some may want to call mental illness?

I see this very clearly after 25 years as a therapist.
People who get anxiety and depression have three positive traits in common:

1.They
are sensitive in a positive sense. They are very aware of others feelings and
actions, and they may react strongly to things that happen in their surroundings,
both positive and negative.

2.They
are analytical and thorough thinkers. They think of all possibilities of what
may go wrong, often like chess players planning for all possible future
problems. “What if” thinking is very useful in hard times, but may be annoying
when conditions are very safe.

3.They
have good imagination. They are able to imagine possible things that may happen
so vividly that they react strongly to them and take action, or avoid possibly
dangerous action in the case of depression.

All psychological problems are on a continuum from not
problematic to very disturbing. It is impossible to put a clear cutoff point,
and what is dysfunctional in one setting may be very desirable in another. That
is why the concept of mental illness is useless. We may talk of patterns of
behavior thoughts and feeling that are more or less functional in different
situations, but it is usually not difficult to see that the behaviors thoughts
and feelings may be appropriate in other contexts. The most classical may be
over active children who would learn much in natural environments but who get
diagnosed for their active exploration in classroom settings.